Social Mobilization and Behavior Change Communication for

This publication was prepared by AED and funded by the United States Agency for International Development undercontract number GHS-I-00-03-00036. It does not necessarily represent the views of USAID or the US Government.September 2009

PREAMBLE:This publication is the product of ongoing collaboration over the past four yearsbetween UNICEF and AI.COMM, a USAID project managed by AED, to design andimplement effective communication programs in developing countries, first for avianinfluenza and more recently for pandemic influenza preparedness and response.AI.COMM has been USAID’s principal mechanism for developing communicationstrategies and tools to prevent and control influenza outbreaks, including those approachesdiscussed in the framework of this document--behavior change communication,social mobilization, policy advocacy, and risk communication. In addition tosharing this framework, UNICEF bases its approach to communication on the humanrights principle that children and adolescents, their families, and communities havethe right to information, communication, and participation. Thus, UNICEF promotesfull participation, gender equity and social inclusion in the development process ingeneral, and in communication in particular.ACKNOWLEDGEMENTS:This document was jointly prepared and funded by UNICEF and AI.COMM. The writingteam was led by Rebecca Fields from AI.COMM and Judith Graeff from UNICEF/New York. Drafts of the document were reviewed by staff from UNICEF, AI.COMM,and USAID, including: Françoise Vanni (UNICEF/Mexico); Surangani Abeyesekera andPatricia Portela Souza (UNICEF/Bangladesh); Sahar Hegazi (UNICEF/Egypt); Tran Tung(UNICEF/Asia Pacific Shared Services Centre); Pornthida Padthong (UNICEF/Thailand);Natalie Fol and Fabio Friscia (UNICEF/West and Central Africa); Paula Claycomb,Teresa Stuart, Neha Kapil, and Jesus Lopez-Macedo (UNICEF/New York); Anton Schneider(AI.COMM/Thailand); Eleanora De Guzman (AI.COMM/Vietnam); Cecile Lantican(AI.COMM/Lao PDR); Yaya Drabo (AI.COMM/West Africa); Phil Sedlak (AI.COMM/Nepal); Soliman Farah (AI.COMM/South Asia); Mark Rasmuson and Dee Bennett (AI.COMM/Washington); and Kama Garrison (USAID/Washington).

IntroductionIn June, 2009, the World Health Organization officially declared that a globalpandemic of type A (H1N1) influenza was under way. One of the critical interventionsto limit the transmission of the disease, mitigate its health impact, and contain thesocial and economic disruption it may cause is to ensure the ongoing provision ofeffective communication.This document provides an overview of strategic communication as it appliesto pandemic influenza in low and middle income countries. It is based both ontechnically sound communication principles and recent experience in severalcountries that have been proactive in communication efforts related to pandemic andavian influenza.The purpose of this document is to provide a framework and guidance to planners fordeveloping country-specific social mobilization and behavior change communicationstrategies for pandemic influenza. These strategies incorporate communicationobjectives, participant groups, desired behaviors, types of messages, selection ofchannels, and approaches to communication planning and implementation in supportof country-level efforts for pandemic influenza response.A key component of the social and behavior change communication processis to integrate the involvement of marginalized and hard-to-reach groups incommunication planning and implementation so that they become active participants- not just passive recipients of information. Involvement not only helps to adaptcommunication strategies and messages to the local context, but also connectsthe perspective of minorities and the hard-to-reach to upstream policy advocacyregarding pandemic response issues—for example, steps to take to reduce inequitiesin economic impact. In addition, access to limited supplies of vaccine and anti-viralmedications could become a critical issue. Communication should play a role inadvocating for equitable access, in accordance with official medical recommendationsfor the use of these products.Some countries may choose to use this guidance to help develop a focused plan ofaction for immediate response, while others may find it useful in drafting a broader,longer-term strategy. This decision will be made depending upon national needs,capacity and the extent of communication planning that has already been carriedout for pandemic influenza. For example, in countries with no, or very few, cases oftype A H1N1 (2009) influenza despite the pandemic, this time of heightened globalawareness can be used as an opportunity to prepare and to strengthen ongoingdevelopment and communication initiatives.Intended users of this PLANNING GUIDANCEThis guidance document is intended primarily for those who are already familiarwith the basic principles of communication planning and implementation. It is nota detailed, “how-to” document with step-by-step instructions on each aspect of7

communication planning and implementation, but rather a concise overview ofcommunication as it pertains to pandemic influenza. For readers seeking moredetailed information, the Resources section of this document provides references andelectronic links to additional documents and websites.This document might also be shared with governments, donors, and within one’s ownorganization to advocate for adequate human, financial and material resources to planand implement effective communication during a pandemic.Technical basis of communication for the H1N1influenza pandemicWHO/UNICEFrecommended behaviors:To reduce transmission:• Keep your distance from someone who iscoughing and sneezing• Stay home if you feel ill• Cover your coughs and sneezes• Wash your hands with soap and waterTo lessen the health impact:• Give sick people a separate space at home• Assign a single caregiver to a sick person• Give plenty of fluids to the sick person• Recognize danger signs and seek prompt care*WHO/UNICEF: Behavioural interventions forreducing the transmission and impact of influenza A(H1N1) virus” June, 2009BOX 1The approaches and contentreflected here support the currentrecommendations on pandemicinfluenza of the World HealthOrganization and other internationalhealth partners. Because the actualcourse of disease for pandemic (H1N1)2009 cannot be predicted with certainty,and because the effectiveness of somepublic health interventions is still beingdetermined, readers are encouragedto consult WHO information sourceson a regular basis. 1 These sourcespresent clearly the recommendedactions that national communicationinitiatives are to promote; key behaviorsare described in Box 1. As the technicalresponse to the pandemic continues toevolve, so must communication effortsto support that response.A coordinated approach to communicationplanningNational governments are the lead authority on pandemic response and communication.Because pandemic influenza has social and economic consequences as well as healthconsequences, representation from a wide range of development partners, bothpublic and private sector, needs to contribute to both pandemic preparedness andresponse. Coordination is also the key to success in planning and implementingstrategic communication for a situation as complex as pandemic influenza.National governments have found that working through a designated coordinationbody with membership to reflect the broad range of partners and stakeholdersimproves the planning and delivery of an effective response, includingcommunication. Rather than creating a new group, some countries have chosen tomake use of existing coordination bodies, adjusting their membership to address1For current, authoritative information on the evolving global situation, readers should consult the WHOwebsite on pandemic (H1N1) 2009 influenza http://www.who.int/csr/disease/swineflu/en/index.html8

BOX 3LESSONS LEARNED ON EFFECTIVE COMMUNICATIONFROM AVIAN INFLUENZA AND SARS EXPERIENCESThese “lessons learned” have been extracted from two surveys of communication experiences gained from severalrecent epidemics. The Waisbord report 2 is based on 19 program reports and 14 national surveys in countriesaffected by avian flu as well as eight in-depth interviews with communication officers in the field. The Schiavo paper 3looked more broadly at lessons learned from avian flu, SARS, Ebola and anthrax outbreaks—conducting a literaturereview and 19 in-depth interviews with a variety of experts working in communication, emergency operations andpublic health, from national governments and global agencies. The consistency of response is striking. The lessonslearned are summarized below. Full versions of these reports can be found on: www.influenzaresources.org1. Communication interventions have been reportedly effective in increasing knowledge. Reports show thatknowledge about modes of transmission, symptoms, safe ways of disposing of sick/dead birds and preventionincreased after communication interventions.2. Increases in knowledge do not necessarily translate into effective behavioral changes. This leads to aconsiderable knowledge-practice gap. Few behavioral changes were found after communication interventions,even when knowledge about prevention and transmission increased.3. Communication interventions should go beyond information transmission given that the lack of knowledge isnot the only or even the main, obstacle to performing desired practices.4. Communication should be integrated with initiatives that reduce obstacles to practicing healthy behaviors.Often, recommended behaviors are not feasible to do—even if an individual is motivated. Wider practice ofrecommended behaviors is often enhanced by changing policy, physical, and economic barriers rather thanfocusing communication on individual attitude and knowledge.5. Easy access and trust are two key considerations in selecting communication channels. These elements will bedifferent for different audiences—thus segmenting audience groups is a critical part of the planning process.6. Engaging trusted community groups and leaders may be more effective in reaching vulnerable/marginalizedgroups than disseminating centrally-generated messages through mass media.7. Communication should address local attitudes and stigma possibly associated with doing the desiredbehaviors.8. Messages should clearly tell people what benefits they would reap if they were to practice the recommendedbehaviors. Benefits should not be limited to conventional public health goals such as “achieving healthycommunities/families” or “preventing disease”. They should also consider a host of immediate social andeconomic rewards that can be associated with desired behavior.9. It is important to clarify expected behavioral and social outcomes and adapt recommended actions to the localcontext.10. Coordination among government counterparts, development partners and UN agencies is crucial for effectivecommunication with harmonized messages. This avoids confusion that can impede widespread adoption ofrecommended behaviors.11. Early integration of medical and scientific teams with communication teams can further contribute to a swiftresponse and to the development of community resilience during an outbreak.12. Timely, strategic, and well-coordinated communication efforts could make a difference not only in mitigatingthe consequences of an emergency, but also in managing people’s reaction during crises. Well managed,credible communication increases the likelihood that recommended behaviors and social actions will beadopted by the population.13. Early participation of key private sector partners, such as physicians and pharmacists, and commercial sectorbusinesses and employers is important so they will take their role in reducing transmission and mitigating thehealth, social and economic impact of the disease.2 Assessment of UNICEF-supported communication initiatives for prevention and control of avian influenza”, Finalreport for UNICEF, Silvio Waisbord, Ph.D., March, 2008.3 “Mapping and review of existing guidance and plans for community and household based communication toprepare and respond to pandemic influenza”, Research report for UNICEF, Renata Schiavo, January, 2009.

public health policy and any social reaction to the response and the disease itself. Animportant part of planning, then, is to decide how key communication partners willremain in contact if working conditions change radically during the pandemic.Lessons learned from past epidemicsWhile communication for pandemic influenza has its own unique attributes, a usefulbody of knowledge exists from outbreaks over the past ten years of Severe AcuteRespiratory Syndrome (SARS), avian influenza, and Ebola virus that can guide currentcommunication initiatives. These are summarized in Box 3.Communication for pandemic response: KeyelementsIn the current response to pandemic (H1N1) 2009 influenza, some countries areable to build upon the communication strategy and activities conducted for avianinfluenza and pandemic preparedness. Other countries are less well prepared. Ineither case, it is important to find a balance between working rapidly to implementthe communication necessary for the response while also respecting the fundamentalsof effective social and behavior change communication—the use of evidence,participation, and adaptation.In order to find this balance, it is useful to rely on existing resources as much aspossible. For example, planners can use existing demographic and social data (suchas from Demographic and Health Surveys – DHS) for selecting participant groups andcommunication channels; or they can use existing networks at the community level forsocial mobilization and behavior change communication.The following key elements should be included in a communication strategy tosupport a country’s response—particularly at the community level—to the currentpandemic influenza.Communication objectives: For communication to be effective, especially ata time of a pandemic when there is uncertainty about how it will affect a country,key partners and stakeholders should reach consensus at the national level on theobjectives of communication. This should happen before an outbreak occurs in thecountry. On a generic level, these objectives include the following:• Help to reduce transmission of disease• Mitigate health impact• Minimize panic and social disruption• Help governments provide credibleinformation during responseSome countries will use this current pandemic todevelop a comprehensive, long-term strategy toencompass newly emerging infectious diseasesand pandemics. Other countries will modify anCommunication objectives needto be the product of joint planningby health officials, communicationspecialists and key partners andstakeholders.12

existing strategy developed for avian influenza and pandemic preparedness, ordevelop a brief strategy just to address the current pandemic.Regardless, the strategy should describe how communication will use a combinationof advocacy, social mobilization and behavior change communication through avariety of channels to achieve each objective. For example, to reduce diseasetransmission:• advocacy to make appropriate policy changes can be carried out with publicand private schools and major employers;• social mobilization activities can be implemented to create a supportiveenvironment for recommended hygiene and cough etiquette behaviors;• behavior change communication activities can be conducted to tailor messagesto the needs of each participant group, including school children, people atwork, parents, and slum dwellers.Any communication strategy should include anaction plan to guide communication activities forimmediate implementation.Key participant groups: Many communicationprofessionals use terms such as target groupor target audience to indicate the segments ofthe population for which the communication isintended; these terms suggest a passive recipientof information. This document, however, uses theterm “participant group” to designate the peopleat various levels who need to take action for aneffective communication response to the pandemic. Suggested participant groupsat all levels and the actions they can take to support appropriate pandemic responseare illustrated in Figure 1 on page 20.The selection of key participant groups should be based on data from previousresearch, current programs, and communication initiatives.Variables to consider when selecting key participant groups are:Each high-risk groupidentified by WHO containswithin it particularlyvulnerable and marginalizedsub-groups who may need tobe reached through specialcommunication efforts.• Epidemiological evidence—Pandemic (H1N1) 2009 mostly affects pregnantwomen, young people (between 5 and 24 years of age), and people withpreexisting health conditions such as asthma, diabetes and obesity. Readers areencouraged to check www.who.int for updated information.• Socially-marginalized groups, such as slum dwellers, minorities, and women arevulnerable to social and economic consequences of any emergency.• Language groups—including languages used by indigenous or immigrantgroups; such groups risk being excluded from the information flow.• Urban and rural populations have access to different channels of information.• Children and adolescents are vulnerable to H1N1 disease, and countryexperience indicates that they are at risk of abuse during a prolongedpandemic. They also risk having interrupted schooling. Children in orphanages,13

correctional institutions, migrant/refugee camps, and boarding schools mighthave no one to advocate for their right to equal access to care.Marginalized groups: An important consideration in pandemic response is how toinvolve and reach socially-marginalized groups in a country. The very fact that they aremarginalized (by ethnicity, race, religion, economic means, displacement, profession)means that they are rarely involved in decisions affecting their well-being and haveless access to information and services. Communication for social and behaviorchange emphasizes inclusion of the marginalized in all steps of the communicationprocess, yet in a pandemic response mode, planners are often pressured to get oneset of messages out to the “general public” as rapidly as possible. Understandingthis reality, following are some possible ways to increase meaningful engagement ofand reach to marginalized groups.a. Work with the government to map traditionally marginalized groups in thecountry and advocate for commitment that they will be reached during thepandemic.b. Identify humanitarian groups (such as the International Red Cross/Crescent,Medecins Sans Frontieres, Catholic Relief Services, and UN humanitarianagencies) that could reach marginalized people and orient/equip these agencieswith appropriate communication materials.c. Involve local leaders or advocacy groups for the marginalized in various aspectsof pandemic response (not just in pre-testing materials!). Representativescan participate in planning how to disseminate prevention messages to theirrespective group(s); help adapt messages to the lifestyle reality of their group;and update the group continually as the pandemic progresses.These steps might be politically sensitive and will take time and resources justwhen they are scarce. But the benefits to the country will be great if marginalizedpopulations feel more engaged and therefore more likely to take appropriate actionin a time of national alert.Desired and feasible behaviors: In May 2009, WHO and UNICEF disseminatedeight key behaviors (shown in Box 1) that will help to reduce transmission and lessenthe health impact of the (H1N1) 2009 influenza. Countries may also choose toadopt some non-health behaviors to the essential list, such as infant feeding, childprotection, and continued learning during school closures.With these behaviors as a starting point, it is important to seek wide participation inhow these behaviors can be adapted to the local context. In addition to discussionswithin the national coordination body, representatives of key minority groups, youth,or other important segments of the population can be included on planning andmessage design teams.Addressing feasibility: In an effort to respond rapidly, some planning teams may notsee the need to adapt recommended behaviors to the realities of the population.Failure to go into more detail about the feasibility of recommended behaviors,however, risks lowering both the effectiveness and the credibility of communicationefforts. For example, how will people cover coughs and sneezes if no cloth or14

Messages should beadapted to reflect:disposable tissues are available? How can sick people stay home if their familydepends on their daily earnings? How can transmission be reduced in schools wherefrequent hand washing and physical distancing are not possible? How can publictransport or daily marketing be made safer? Taking the time to address these issuesin developing a list of feasible behaviors will improve their widespread adoption.Making some behaviors feasible for individuals is often better addressed atthe policy level. The last two questions above might be better addressed withtemporary policy changes rather than an emphasis on individual behavior change.To lower transmission at work settings—another example—temporary changes inscheduling, work space and work processes could improve hand washing possibilities,facilitate safe disposal of tissues and face masks, and lower occasions for closecontact. Communication plans should include policy advocacy to trigger timely andappropriate decisions by government and pandemic partners to support adoption ofrecommended behaviors to scale.Adapted messages: Sometimes the first reactionplanners have to the time pressure during pandemicresponse is to develop generic messages based onscientific evidence alone. Planners often think thattranslating generic messages into multiple local languagesis a sufficient way to adapt them. However, messagesbased exclusively on technical content are unlikely tobe fully effective in promoting desired behaviors andsocial action. Messages need to reflect local perceptionsof risk and disease transmission and an understandingof the perceived consequences to performing desiredbehaviors. Emotional appeal is also important in messagedevelopment. In some countries, social research data willbe available to inform the design of messages. But if not,it will be particularly important to conduct a small numberof focus group discussions with selected participant groupsto assure (at a minimum) that messages are understoodand acceptable. As stated earlier, representatives of keyparticipant groups should participate in communication planning (such as messagedevelopment workshops) to facilitate adaptation of messages to these groups.• Local perceptions ofdisease transmission• Feasible and locallyrelevantcalls to action• Perceived consequencesto performing thebehavior• Emotional appealOne serious issue that has arisen in some countries that have been hard hit bythe 2009 influenza pandemic is stigma against sick people and members of theirhouseholds. Communication teams should anticipate this possibility and revise theirmessages as needed to promote supportive actions and care toward those who aredirectly or indirectly affected by pandemic influenza.Credible sources of information and appropriate channels: The channelsto use during the pandemic are likely to vary widely depending upon how differentsegments of the population (participant groups) access and use information. As muchas possible, planners can use existing data to determine access and credibility ofcommunication channels for the participant groups mentioned in the communication15

strategy. For example, there may be substantial differences between urban and ruralareas regarding access to and credibility of messages provided through mass media.In the early stages of a country’s response to the pandemic, radio, TV, and flyers/posters are often the channels of choice. Their advantage is their broad reach andability to handle “fast-breaking news”. Butmany countries have discovered that as theCOMMUNICATIONCHANNELSMASS MEDIA: Television,radio, newspapers, posters,billboards, leafletsTRADITIONAL MEDIA: folktheatre, puppets, poetry/song, social & religiousgatheringsINTERPERSONALCOMMUNICATION:household visits,courtyard meetings,health education, socialmobilization, school activitiesNEW MEDIA: Cell phones,SMS, internet (websites,blogs, Twitter), telephonehotlinespandemic continues, other channels need to beused to reach effectively different participantgroups such as school children, pregnantwomen, indigenous peoples. For example,interpersonal communication from trustedsources is likely to be important to reachmarginalized populations or those outside thereach of broadcast media. (See section onpartners for social mobilization below).Interpersonal communication (IPC) channels,having limited reach, can reinforce andpersonalize the general information providedthrough mass media channels and can provideopportunities for dialogue and problemsolvingthat other channels cannot. In a highlycontagious influenza pandemic, however,the use of IPC might be limited because ofpotential transmission opportunities. Ways touse IPC without close physical contact includeusing megaphones, remaining outside duringhousehold visits, and not giving handouts.Health care providers and community healthworkers can play a role in IPC during thepandemic. Yet, when an outbreak occurs, healthcare services can be overwhelmed and healthworkers are likely to be overtaken by clinicalduties; so their role as communicators can be greatly compromised. While theycannot provide typical health education sessions during an outbreak, they can learnto communicate with patients and families during clinical care. Thus, health workersshould be prepared so that they can provide key information, respond to the concernsof their patients, and communicate their patients’ concerns onward as needed. Thenational and local coordinating bodies should determine who will take responsibilityfor communication training of health workers so that it is integrated into the nationalcommunication plan.The education system is an important communication channel in pandemicresponse—both through policy decisions and through promoting preventivebehaviors while schools are in session. Behavior change communication can reachstudents through age-appropriate lessons, games and songs as well as through16

peer group interaction. Teachers and students are often seen as credible sources ofinformation and can be mobilized for outreach to the community.Many countries are experimenting with new media (see text box) to help in pandemiccommunication. While cell phone ownership is high in many countries, informationcoming via SMS is usually not seen as credible. Use of cell phones, where available,might be used more effectively to update and coordinate field workers and socialmobilization partners. The use of multiple channels is important for effectivecommunication, but keeping efforts coordinated and information consistent acrosschannels is a major challenge during pandemic response. Advanced planning and anactive national communication coordination body will help to minimize confusion.Advocacy: During the response to the pandemic, advocacy can be used withvarious ministries outside of health (for example, education, child welfare, tourism) toengage them in policy decisions at the national level to help reduce transmission andmitigate the social and economic impact. Examples of such policy decisions includewhether to screen passengers at airports and place other restrictions on travel; andwhether to use school closure or class dismissal as public health measures. Additionaladvocacy efforts may be needed to convince non-traditional partners, such as privatesector organizations and businesses, that they have a stake in pandemic response.For example, factory owners, the private education system, and agri-business can becalled upon to adjust temporarily their employment policies regarding absenteeism.(See “Desired and Feasible Behaviors” to see how policy change can help makedesired behaviors more do-able for individuals.) All organizations should be urgedto adopt business continuity measures, but this is especially important for thoseorganizations providing essential services to the public.Advocacy at the sub-national levels is also critical for coordinated planning andimplementation to reach to the community level. In large countries or those withdecentralized political systems, provincial/district authorities may be called uponto develop their own preparedness and response plans. At the very least, localauthorities need to be oriented on the government’s response plan so that theycan guide implementation in their area and communicate to their constituents inharmony with national decisions. Coordination of social mobilization and othercommunity-level initiatives to reduce transmission might also rest with sub-nationalcommunication teams. Therefore, national communication planners should engagerepresentatives of key sub-national levels to develop realistic implementation plans.Partners for socialmobilization: Before anoutbreak occurs, a few keygroups should be selectedand agreements made abouthow they will be used forcommunication during thepandemic response. Civilsociety organizations, religiousand community leaders, privatesector health providers andBefore an outbreak, enlist the support of:• Civil society organizations and NGOs• Religious and community leaders• Private health providers and pharmacists• Major employers and private industries• Networks such as teachers and studentpeer groups17

pharmacists, major employers, NGOs and other development agencies are someof the partners to mobilize during the pandemic to reach out to people at thecommunity level. Existing networks outside of the health sector can also be importantpartners in communication. These may include hygiene promoters in water andsanitation programs, community catalysts/mobilizers, agricultural extension workers,micro-credit groups, educational networks such as teachers, administrators, andstudent peer groups, and village development committees. One country successfullyengaged herbal medicine vendors in rural markets to transmit prevention messagesto their clients.It is particularly important to find groups which can reach and are credible to someof the minorities, socially marginalized and other participant groups identified in thecommunication strategy.To assure that these groups communicate correct information effectively, speciallyadaptedmaterials and orientation to their use will be important components of thecommunication plan. A monitoring plan that includes tracking how mobilizers are todeliver messages as the pandemic unfolds will be important to harmonize messages,minimize the spread of rumors, and maintain morale. Two-way communicationbetween mobilizers and their field supervisor/leader should be agreed upon. Forexample, planners could explore the use of regular contact by mobile phone.Behavior change communication (BCC): Behavior change communicationfocuses on individuals and their behavior. This guidance focuses on BCC and how itis effectively combined with other communication approaches to support pandemicresponse. Specifically, the role of BCC during the pandemic is to inform andmotivate individuals to adopt the behaviors recommended to prevent contracting theH1N1 virus, limit its spread to others and to promote home care of the sick. Thesemessages to individuals are spread through various channels which were describedabove. One effective way to motivate individuals is to engage popular and trustedpersonalities in addition to the official government spokespersons as sources ofinformation.Using a combination of mass media, interpersonal communication and traditionalmedia will increase the effectiveness of messages to different participant groups.Examples of the kinds of materials and messages focusing on the individual and whathe/she should do during the pandemic can be found on these (among other) websites: www.pandemicpreparedness.org and www.influenzaresources.org.Risk/outbreak communication: As stated earlier, this is the term used for thecommunication between health and government authorities and the population of acountry in a pandemic situation before and in response to an outbreak in that country.It is well documented that when government and other authorities are transparentby providing timely and correct information to the population, their efforts to reducetransmission and mitigate the impact of the pandemic are more successful. Effectiverisk communication, however, takes planning and capacity building, including:• Identification and training of spokespersons from government and otherselected agencies—for coordination and consistent messaging18

• Media training and continued orientation—for informed and balanced reporting• During response: regular updates to the public from authorities via mass media;maintenance of quality websites and other information sources; regular updatesto hard-to-reach groups via pre-arranged communication channels; monitoringfor reach and rumors.Research and monitoring: Research during planning is important to understandparticipant groups’ perceptions of riskand feasibility of protective behaviorsand to prepare/adapt messagesand materials. Because of the timeconstraint, planners should use existingdata sources as much as possible. Forexample, Demographic and HealthSurveys (DHS), carried out in manycountries, contain useful descriptiveinformation about households andcommunities which can help informthe design of actionable messages andidentify the most effective channelsfor communication. Previous researchconducted for avian influenza, childsurvival, nutrition, personal hygiene,child protection, HIV/AIDS prevention,etc. that emphasized social andcultural determinants are good sources of evidence to help make the pandemiccommunication more strategic.If resources for research and monitoringare limited, focus on• existing sources of information (such ashousehold surveys)• formative research to understandperceptions of risk and feasibility ofprotective behaviors and• pre-testing of communication productsand messages• monitoring the reach of communicationchannels to key participant groupsGiven likely resource constraints, it may not be possible or essential to carry outquantitative baseline surveys about knowledge, attitudes, and behaviors specificallyrelating to pandemic influenza. While it would be desirable to have this information inorder to measure the effectiveness of communication activities, it is likely to be moreuseful if the limited resources available are applied to pre-testing and monitoringactivities, as described below.Pre-testing: All communication products, including the feasibility of recommendedbehaviors, need to be pre-tested in a systematic way with the intended participantgroup. Taking time and resources to test messages and materials for comprehensionand acceptability with communities before being approved by governmentauthorities/communication committees will be more effective in achievingcommunication objectives. If possible, negotiate a contract in advance with a localresearch firm, experienced in communication pre-testing, so that it can be rapidlydeployed when the communication messages and materials are ready.Monitoring plans do not need to be extensive. They should match the level of effortdevoted to pandemic-specific communication. Basically, the reach of communicationthrough the most heavily-used channels (including the deployment of socialmobilizers) should be monitored frequently during response—especially to trackefforts to reach socially marginalized and hard-to-reach populations. Proxy indicators19

FIGURE 1LEVELS PARTICIPANT* ACTIONSNationalPandemicCoordinationbody, CommunicationTask Force, donors,private sector, nationalmedia, development partnersAdvocacy for government transparency and appropriate policy decisions; rights ofmarginalized groups protected; continuous work through national coordination bodies tosupport pandemic response; resources allocated for communication; strategy andmaterials developed; authorities and media trained in risk communication; use of massmedia; collection, analysis and use of research and monitoring dataSub-nationalDistrict, municipality, etc.Local government officials, districtMOH/MOE team, NGOs, hospitaladministration, border authoritiesLocal level advocacy for transparency and coordination of communicationand public health response; harmonize messages; leadership trained in riskcommunication; social mobilizationHealth facilityHealth providers (public, private & faith based)Through IPC, use harmonized messages about reducingtransmission and providing home care.CommunityCSOs, community and religious leaders, women’s groups,CHWs, teachers/school committees, youth groupsUse traditional media, social mobilization, BCC incommunity and schools to reduce transmission,facilitate home care and social support.Household &IndividualParents, adult care-givers, adolescents, other household members, childrenPractice behaviors for home care,to reduce transmission, andmitigate social impact.* Participants are decision makers and stakeholders who need to take the actions described.BCC – behavior change communicationCHWs – community health workersCSOs – civil society organizationsMOH – Ministry of HealthMOE – Ministry of EducationNGO – nongovernmental organization20

Suggested resource materialsThe Humanitarian Pandemic Preparedness (H2P) Initiative, UNICEF, and their partnershave worked closely with WHO and other public health agencies to develop a rangeof guidance documents and communication materials. These agencies and othersmaintain websites with specific links to the H1N1 pandemic. As these sites continueto evolve and additional resource materials are made available, readers are advised tocheck the websites listed below on a periodic basis.World Health Organization website for pandemic H1N1 (2009) influenza:http://www.who.int/csr/disease/swineflu/en/index.htmlMulti-agency link for avian and pandemic communication resources:www.influenzaresources.orgH2P link for communication resources:www.pandemicpreparedness.orgUseful resource documents include the following:Behavioural interventions for reducing the transmission and impact of influenzaA(H1N1) virus: a framework for communication strategies (WHO/UNICEF, June2009). Available at:http://www.who.int/csr/resources/publications/swineflu/framework_20090626_en.pdfDrawing Attention to Pandemic Influenza through Advocacy. March 2009.Available at: http://avianflu.aed.org/globalpreparedness.htmEssentials for Excellence: Researching, Monitoring and Evaluating StrategicCommunication for Behavior and Social Change with special reference to theprevention and control of avian influenza/pandemic influenza (2008). Available at:http://www.unicef.org/cbsc/files/Essentials_for_excellence.pdfGlobal Preparedness for Pandemic Flu – Advocacy Kit. Available at:http://avianflu.aed.org/globalpreparedness.htm“Spreading the Word: Preventive Messages about Flu”. Training module forcommunity health responders. Available on the H2P Website or on the COREGroup website at: www.coregroup.org/h2pWHO Outbreak Communication Guide, 2008http://www.who.int/ihr/elibrary/WHOOutbreakCommsPlanngGuide.pdf“Terms of reference for a national Avian and Pandemic Communication task force”www.influenzaresources.org22